Responsibilities

JOB SUMMARY: Performs timely, daily clinical reviews with all payer types, to secure authorization for initial and continued treatment based on payer’s criteria and in accordance with the hospital wide Utilization Management Plan. Serves as liaison to 3rd and 4th party reviewers, effectively coordinating collection of all supporting data to support the hospital and patients’ position. Functions as a key member of the multidisciplinary treatment team to educate and guide on level of care requirements and payer expectations for patient acuity and appropriate utilization. Completes quality and timely appeal/denial letters. Participates in post claim recovery review and ongoing audit activity, supporting compliance with CMS and other regulators. Works collectively with hospital operations to ensure timely documentation is aligned with patient conditions. Contributes to monthly utilization data trends using hospital data tools to report for the overall operation. Facilitates physician reviews with payers as required. Maintains all records/data pertaining to the Utilization Management Program. Actively participates in Utilization Management/Medical Records Committee meetings including presentation of reports, statistics, etc. Participates in the hospital-wide Quality Assurance Program.

Qualifications

JOB SPECIFICATIONS: To perform this job successfully, an individual must be able to perform each primary duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required.

Education: Bachelor’s Degree in Behavioral Health Field required; Master Degree preferred.

Experience: 1 year experience in Utilization Management; 1 year experience in mental health/psychiatry preferred

Licensure/Certification: None

Knowledge: Possesses knowledge of utilization management, insurance and managed care procedures. Current knowledge of regulating /accrediting agency guidelines. Basic knowledge of computer skills and statistical analysis desired. Knowledgeable in behavioral health managed care and clinical assessment skills to align patient acuity with level of care practice guidelines - Diagnostic and Statistical Manual of Mental Disorders (DSM-V). Effective oral and written communication skills to support patient advocacy/negotiating skills to ensure quality reviews with payers.